3.2.2. Combination inhaled devices
In asthma, patients receiving inhaled corticosteroids should have their treatment reviewed regularly with those patients on a high-dose inhaled steroid being considered for step-down if appropriate. Patients receiving >1000 micrograms of 'traditional' beclometasone daily (or equivalent, e.g. fluticasone 500 microgram or budesonide 800 microgram) should be issued with a steroid card.
Restrictions:
Asthma: Refer to NHSGGC Inhaler Device Guide for place in therapy in adults.
COPD: Use of the 100/6 strength for the treatment of severe COPD is restricted to use in accordance with the current NHSGGC COPD Inhaler Device Guide.
Prescribing Notes:
Preferred brand and devices:
- Fostair NEXTHaler® (dry powder inhaler)
- Luforbec® (aerosol inhaler)
To prevent confusion, prescribe inhaler devices by brand name.
In selected adult patients with asthma, the use of beclometasone and formoterol 100/6 in a single inhaler as rescue medication instead of a short-acting beta2 agonist, in addition to its regular use as controller therapy, has been shown to be an effective treatment regime.
Fostair 200/6 and Luforbec 200/6 strength aerosol inhaler are not currently licensed for use in COPD or for the maintenance and relief use in asthma (as described in the paragraph above).
Restrictions:
COPD: The symptomatic treatment of adults with chronic obstructive pulmonary disease (COPD) with an exacerbation history despite regular bronchodilator therapy is restricted to use in patients with severe COPD (FEV1 <50% predicted normal).
Asthma: The regular treatment of asthma in adults and adolescents aged 12 years and older where use of a combination medicinal product (long-acting beta2-agonist and inhaled corticosteroid) is appropriate in patients not adequately controlled with inhaled corticosteroids and 'as needed' inhaled short-acting beta2-agonists
Prescribing Notes:
To prevent confusion, prescribe inhaler devices by brand name.
- Fluticasone furoate is a high-potency inhaled steroid (with a dose of 92 micrograms once daily broadly equivalent to 250 micrograms twice daily of fluticasone propionate). When used for asthma, due consideration for the likelihood of step-down should be given prior to initiation as there are no available step-down options containing a dose lower than 92 microgram of fluticasone furoate.
- Prescribers should be aware that the fluticasone furoate contained in this preparation is not equivalent in terms of dosing to fluticasone propionate.
- The Summary of product characteristics for this preparation advises on dose equivalence in section 4.2.
- It should be noted that once the inhaler has been opened from its foil packaging, it has an expiry of 6 weeks.
- The name of this device may inadvertently lead patients to confuse it as a 'reliever'. Careful counselling to avoid overuse is advised.
- Only the 92/22 microgram strength is licensed for COPD
Restrictions:
COPD: Restricted to severe COPD (FEV1 <50% predicted normal)
Prescribing Notes:
Formulary devices and indications:
- Trimbow NEXThaler® (dry powder inhaler): COPD
- Trimbow® (aerosol inhaler 87 microgram/5 microgram/9 microgram): asthma and COPD
- Trimbow® (aerosol inhaler 172 microgram/5 microgram/9 microgram): asthma
Click here to see inhaler device guides.
Restrictions:
Restricted for use in asthma patients according to the BTS/SIGN asthma guidelines.
Prescribing Notes:
Preferred brands and devices:
- DuoResp® Spiromax (dry powder inhaler)
- Symbicort® Turbohaler (dry powder inhaler)
To prevent confusion, prescribe inhaler devices by brand name.
In terms of comparative doses, one dose of Duoresp® 160/4.5 delivers an equivalent amount of the constituents as one dose of Symbicort® 200/6. Similary, DuoResp ® 320/9 is the equivalent of Symbicort® 400/12.
In selected adult patients with asthma, the use of budesonide and formoterol in a single inhaler as rescue medication instead of a short-acting beta2 agonist, in addition to its regular use as controller therapy, has been shown to be an effective treatment regime.
Non-Formulary indication:
Treatment of patients with chronic obstructive pulmonary disease (COPD) with forced expiratory volume in 1 second (FEV1) 50% to 70% predicted normal (post bronchodilator) and an exacerbation history despite regular bronchodilator therapy.
Restrictions:
Restricted to use in patients with severe COPD (forced expiratory volume in one second [FEV1] less
than 50% predicted normal).